From the Guidelines
The workup and management of a pathological fracture should prioritize a multidisciplinary approach, including interventional radiology, surgery, and radiation oncology consultation, to address both the fracture and its underlying cause, with the goal of reducing morbidity, mortality, and improving quality of life. The initial evaluation should include a thorough history and physical examination, focusing on risk factors for metabolic bone disease, malignancy, or infection. Imaging studies, such as plain radiographs, CT, or MRI, are essential to characterize the lesion and assess soft tissue involvement 1. Laboratory tests, including complete blood count, comprehensive metabolic panel, and tumor markers, should be performed to establish a definitive diagnosis.
For patients with pathologic fracture with severe and worsening pain, a multidisciplinary approach, including interventional radiology, surgery, and radiation oncology consultation, is recommended, with percutaneous thermal ablation or percutaneous vertebral augmentation (VA) usually appropriate 1. In cases with spinal deformity or pulmonary dysfunction, a multidisciplinary approach, including interventional radiology, surgery, and radiation oncology consultation, is also recommended, with percutaneous VA usually appropriate 1.
Management involves stabilizing the fracture while addressing the underlying pathology, with treatment guided by the underlying cause, such as metastatic disease, primary bone tumors, or osteoporosis. For fractures due to metastatic disease, treatment typically includes surgical stabilization, followed by radiation therapy, and systemic therapy, such as bisphosphonates or denosumab, to reduce skeletal-related events 1. Rehabilitation with protected weight-bearing and physical therapy should be initiated early to maintain function while allowing bone healing.
Key considerations in the management of pathological fractures include:
- A multidisciplinary approach to address both the fracture and its underlying cause
- Imaging studies to characterize the lesion and assess soft tissue involvement
- Laboratory tests to establish a definitive diagnosis
- Treatment guided by the underlying cause, such as metastatic disease, primary bone tumors, or osteoporosis
- Rehabilitation with protected weight-bearing and physical therapy to maintain function while allowing bone healing.
From the FDA Drug Label
Each study evaluated skeletal-related events (SREs), defined as any of the following: pathologic fracture, radiation therapy to bone, surgery to bone, or spinal cord compression.
The workup and management for a pathological fracture is not directly addressed in the provided drug label. The FDA drug label does not answer the question.
From the Research
Pathological Fracture Workup
The workup for a pathological fracture involves diagnosing the underlying cause of the fracture, which is essential for subsequent therapy 2. This can be achieved through:
- Clinical detection
- Radiological assessment
- Histological diagnosis
Management of Pathological Fractures
The management of pathological fractures depends on the underlying cause and can include:
- Conservative therapy, which is possible in some cases 3
- Surgical treatment, which is often necessary, especially in cases of malignant pathologic fractures 3, 4
- Adjuvant therapy, which may be combined with surgery 3
- Bone-modifying agents, such as bisphosphonates and denosumab, which can be used to prevent skeletal-related events in cancer patients with bone metastases 5
Prognostic Factors
The prognosis following a pathological fracture is often poor, with a median survival time of 3.3 months in one study 4. Factors that can affect prognosis include:
- Primary cancer type
- Fracture site
- Method of fixation
- Presence of visceral metastases
- Patient co-morbidities
- Functional performance score
Treatment Options
Treatment options for pathological fractures can vary depending on the underlying cause and the patient's condition. These may include: